Biopsychosocial Aspects of Functional Gastrointestinal Disorders

Abstract

In this paper, we provide a general framework for understanding the functional gastrointestinal disorders (FGID) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of the FGID. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individual's family, the individual's own psychological states and traits, and the individual's (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools which can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGID.

Keywords: Adverse life events; anxiety; cognitive behavioral therapy; depression; exposure treatments; hypnosis; somatic symptom disorder.

Figure 1.

Biopsychosocial Model of IBS. Genetic and environmental factors, such as early life experiences, trauma, and social learning, influence both the brain and the gut, which in turn interact bidirectionally via the autonomic nervous system and the HPA axis. The integrated effects of altered physiology and the person’s psychosocial status will determine the illness experience and ultimately the clinical outcome. Furthermore, the outcomes will in turn affect the severity of the disorder. The implication is that psychosocial factors are essential to the understanding of IBS pathophysiology and the formulation of an effective treatment plan. Figure adapted from Drossman et al,¹⁰⁹ with permission.

Figure 2.

Associations between maternal reinforcement and parental IBS, and illness behavior. In addition to increased reported severity, children whose mothers strongly reinforce illness behavior also experience more school absences than other children. Figure adapted from Levy et al, with permission.

Figure 3.

Gastrointestinal-symptom specific anxiety: when normal becomes threatening. Gastrointestinal symptom-specific anxiety is an important perpetuating factor of FGID and is characterized by worry and hypervigilance around GI sensations that can range from normal bodily functions (hunger, satiety, gas) to symptoms related to an existing GI condition (abdominal pain, diarrhea, urgency). The worry and hypervigilance usually generalize into fear regarding the potential for sensations or symptoms to occur and/or the contexts in which they may be most likely to present. Gastrointestinal symptom-specific anxiety can result in avoidance and behaviors out of proportion to symptoms.

Figure 4.

Overview of pathways through which psychological processes exert their role in functional gastrointestinal disorders. The “emotional motor system” consists mainly of subcortical and brain stem areas (amygdala, hypothalamus, and periaqueductal gray matter) that are crucial in relaying descending modulatory output from affective and cognitive cortical circuitry, as well as regulating autonomic and HPA axis output. CRF, corticotrophin-releasing factor. Figure adapted from Van Oudenhove and Aziz and Naliboff and Rhudy,¹¹⁰ with permission.